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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410503100
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:43:37 PM

Document Has Been Signed on 03/28/2024 01:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PHILLIPS BROOKS NURSERY SCHOOLFACILITY NUMBER:
410503100
ADMINISTRATOR:OLDENBURG, ZACFACILITY TYPE:
850
ADDRESS:2245 AVY AVE.TELEPHONE:
(650) 854-4545
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 67TOTAL ENROLLED CHILDREN: 66CENSUS: 61DATE:
03/28/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Zac OldenburgTIME COMPLETED:
02:15 PM
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On March 28th, 2024, Licensing Program Analyst (LPA) Kassandra Medrano conducted an unannounced, case management inspection regarding lead testing for childcare centers. LPA met with Zac Oldenburg, Director, and explained the purpose of the inspection. Present during the inspection included 61 children and 6 staff including the director and 3 lunch time volunteers.

Prior to today’s inspection, on 4/6/2023, California Rural Water Association (CRWA) tested the facility's faucets for lead. Children have access to drinking water at facility from the faucets that have been tested by CRWA. Per CRWA facility has received passing results. LPA discussed Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the facility representative during the inspection. All Child Care Centers that are licensed in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.


Facility is being cited a Type B citation for not completing lead water testing requirement prior to due date. Appeal rights were provided. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility representative, Zac Oldenburg.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 01:43 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 03/28/2024 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PHILLIPS BROOKS NURSERY SCHOOL
FACILITY NUMBER: 410503100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
HSC
1597.16(a)(1)

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A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test
This requirement was not met as evidenced by:
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Facility to send documentation of required documents as well as post the required documents.
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Based on review of water site, facility tested on 4/6/23 which was after the deadline of 1/1/23. This posed a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
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